Pain and Dependence: screening for addiction in a pain setting North British Pain Association May 2008 Drs Steve Gilbert and Alex Baldacchino NHS Fife

North British Pain Association

May 2008

Drs Steve Gilbert and Alex Baldacchino

NHS Fife

Overview Drugs and dependence in a pain setting: what does the literature tell us The process of change Dependence Assessment Objective signs

Drugs and dependence in a pain setting: what does the literature tell us

The process of change

Dependence

Assessment

Objective signs

Historical Perspective

Opiophobia! The Hospice movement 1960’s WHO Pain Ladder BUT…… European Pain In Cancer 2007 (EPIC)‏ 50% had moderate to severe pain Option of strong opioids not offered 20% had no pain treatment

The Hospice movement 1960’s

WHO Pain Ladder

BUT……

European Pain In Cancer 2007 (EPIC)‏

50% had moderate to severe pain

Option of strong opioids not offered

20% had no pain treatment

PAIN IN EUROPE 2004 Strong opioids for non malignant pain Ireland - 13% Britain – 12% Denmark -11% Holland – 5% France Germany & Poland - 4% Spain - 1% Italy - 0% Britain had the highest proportion of patients on opioids - 50% on “weak opioids” + 12% on “strong”

Strong opioids for non malignant pain

Ireland - 13%

Britain – 12%

Denmark -11%

Holland – 5%

France Germany & Poland - 4%

Spain - 1%

Italy - 0%

Britain had the highest proportion of patients on opioids - 50% on “weak opioids”

+ 12% on “strong”

Where are we now? Do opiates improve pain & function in chronic pain? Portenoy & Foley 1986 - YES! BUT! short term – focusing on pain score Long term follow up not so optimistic

Do opiates improve pain & function in chronic pain?

Portenoy & Foley 1986 - YES!

BUT!

short term – focusing on pain score

Long term follow up not so optimistic

The Danish experience

Eriksen & the Danish Experience Cross sectional census of population Those on opiates had more pain AND less ability Mounting levels of prescription drug abuse More rather than less health service utilisation Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain. An epidemiological study. Pain 2006;125:172–9

Cross sectional census of population

Those on opiates had more pain

AND less ability

Mounting levels of prescription drug abuse

More rather than less health service utilisation

Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical

issues on opioids in chronic non-cancer pain. An epidemiological

study. Pain 2006;125:172–9

Good Advice?

Problem Use and Dependence Drug use terminology What is problem use? What is dependence? The alcohol dependence syndrome Relationship between problems and dependence

Drug use terminology

What is problem use?

What is dependence?

The alcohol dependence syndrome

Relationship between problems and dependence

Drinking and drug using careers What is a drug-taking career? Why do we need to know about drug taking careers? Moving into and out of the drug-taking career Does treatment alter drug and alcohol careers?

What is a drug-taking career?

Why do we need to know about drug taking careers?

Moving into and out of the drug-taking career

Does treatment alter drug and alcohol careers?

The process of change Why is it important to understand change? How does it feel? A process of change model Motivational interviewing

Why is it important to understand change?

How does it feel?

A process of change model

Motivational interviewing

WHAT CAN I OFFER A NEWLY PRESENTING DRUG USER? Accept your limits & define your philosophy / boundaries What can I do? What can’t I do? What will I do? What won’t I do? With what do I need help? Where can I get it?

Accept your limits & define your philosophy / boundaries

What can I do?

What can’t I do?

What will I do?

What won’t I do?

With what do I need help?

Where can I get it?

The Assessment Process The drug & medical history Examination Screening for drug use Therapeutic boundaries and goal setting Objective investigations

The drug & medical history

Examination

Screening for drug use

Therapeutic boundaries and goal setting

Objective investigations

The Drug & Medical History Why has the patient presented to you now? How has the patient presented? Screening: AUDIT and DUDIT Assessment of their current drug use (last 4 weeks)‏ Past drug history Previous treatments Assessing risk-taking behaviour Assessment of physical health Assessment of psychological health and motivation Assessment of social situation

Why has the patient presented to you now?

How has the patient presented?

Screening: AUDIT and DUDIT

Assessment of their current drug use (last 4 weeks)‏

Past drug history

Previous treatments

Assessing risk-taking behaviour

Assessment of physical health

Assessment of psychological health and motivation

Assessment of social situation

Examination General state Examination of the skin Assessment of Resp & CVS systems Abdominal examination Musculoskeletal system CNS Special problems for women users Contraception Osteoporosis

General state

Examination of the skin

Assessment of Resp & CVS systems

Abdominal examination

Musculoskeletal system

CNS

Special problems for women users

Contraception

Osteoporosis

Objective signs for drug use Why do this? To confirm the patient is using drugs and which ones To help decide on the treatment plan For your medicolegal protection For the patients protection To help reduce street diversion To encourage honesty

Why do this?

To confirm the patient is using drugs and which ones

To help decide on the treatment plan

For your medicolegal protection

For the patients protection

To help reduce street diversion

To encourage honesty

Objective signs Routine urinalysis Routine bloods may be difficult Hepatitis and other BBV serology

Routine urinalysis

Routine bloods may be difficult

Hepatitis and other BBV serology

Goal setting Important to identify goals so that treatment has direction and focus Clearly identified collaboratively with the patient Specific, attainable and measurable split into short and long term Help the patient to think about how these changes may be brought about Assessment is a process and should be sequential and ongoing as an individuals needs develop

Important to identify goals so that treatment has direction and focus

Clearly identified collaboratively with the patient

Specific, attainable and measurable split into short and long term

Help the patient to think about how these changes may be brought about

Assessment is a process and should be sequential and ongoing as an individuals needs develop

WHAT CAN I OFFER A NEWLY PRESENTING DRUG USER? Brief interventions F eedback R esponsibility A dvice M enu E mpathy S elf-efficacy

Brief interventions

F eedback

R esponsibility

A dvice

M enu

E mpathy

S elf-efficacy